Patient Name

Evaluation date

Therapist Name

Primary Medical Physician

Primary Medical Physician Phone

Previous diagnostic tests/ Results(MRI, X-Rays, Labs, etc.)

Pain feels like

burning

tingling

sharp

stabbing

On a scale of 1-10, the worst being 10. What level of pain do you have when doing a movement or activity that bothers you?

PAIN LEVEL:

What happened to cause symptoms

If you were to prioritize your symptoms- which are keeping you from having an active quality of life, please tell me what is the number one thing that bothers you the most?

Priority #1 Pain:

How long have you had this pain?

Priority #1 Other symptoms

How long have you had these other symptoms?

When did you first have symptoms

What activity have you stopped due to pain

What have you done to relieve symptoms

What other therapies have you tried

Have you had Surgery for your symptoms

Have you been told you need surgery for your symptoms

Are you taking medication for your symptoms

Movement that bothers you most

Anyone in your family diagnosed with the following? (check all that apply)

RSDS (Reflex Sympathetic Dystrophy Syndrome)- also known as complex regional pain syndrome, is a rare disorder of the sympathetic nervous system that is characterized by chronic, severe pain.

Fibromyalgia

POTS (Postural Orthostatic Tachycardia Syndrome (Elevated HR upon standing 120+BPM)

Spinal Cord Injury

Concussion

Stroke

When was the last time you did the activity without pain

Is there a priority #2?

Is there a priority #3

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